Pain may be the sixth vital sign, but it is certainly not the least.
Just look at how many organizations are devoted to researching and treating pain. There's the American Pain Society, American Academy of Pain Medicine, American Academy of Pain Management, American Chronic Pain Association and the American Society for Pain Management Nursing (ASPMN), to name a few. Pain research facilities are cropping up all over the country, to say nothing of pain centers that treat patients with chronic pain.
As many professional organizations as there are for pain, there are more pain scales to classify patients' pain. There is the FLACC, the Wong-Baker Faces, Numerical Rating Scale, COMFORT, CRIES, Brief Pain Inventory, Coloured Analogue Scale, Alder Hey Triage Pain Score, McGill Pain Questionnaire and the Checklist of Nonverbal Indicators - the list goes on and on.
Healthcare groups are addressing pain as well. The Joint Commission recognized hospitals that had excellent pain programs in its last annual quality and safety report, and the Institute of Medicine called for a national pain program in a June 2011 position paper.1,2
"Every healthcare provider thinks about pain," said Joyce S. Willens, PhD, RN-BC, president-elect of the ASPMN.
However, even 11 years into the 21st century, pain still presents many of the challenges it did centuries ago.
"If you don't get pain treatment right, not much else is going to work," said Loretta Kaes, BSN, RN, BC-G, C-AL, director of quality assurance and clinical services at the Health Care Association of New Jersey, an organization that regularly updates its pain management best practices guideline.
"Pain is a mixed blessing. It can tell us when something is wrong, but when it becomes chronic it can make our lives unbearable," said historian Marcia L. Meldrum, PhD, co-director of the John C. Liebeskind History of Pain Collection at the University of California, Los Angeles.
"At this point, physicians often don't know what pain measurement means to an individual patient. We know that pain is what the patient says it is, but bottom line, there is no one single pain modality, no pain treatment that works for everyone, not even opioids," she explained.
That presents a conundrum in establishing evidence-based practices for pain management, experts say.
"By its very nature, it is difficult to research and define which medications best alleviate what type of pain," Meldrum told ADVANCE. "After all you can't inflict serious persistent pain on groups of people and ask them to assess their experiences. That's not ethical."
Attitudes Toward Pain
The issue is further clouded by cultural differences in pain perception, century-old prejudices regarding pain that linger today, and a lack of understanding of how exactly pain is relieved.
It is significant that the first definition for pain in Merriam Webster Dictionary is "punishment," because, as Meldrum explained, until modern times, pain "was a faith-testing experience, a way to build character and very often considered a punishment for past misdeeds."
"The World War II generation was raised to be stoic, buck up, don't bother the doctor; people will think you're weak if you complain," Kaes observed, drawing upon her experience as an assisted living nurse.
"John Homans [MD, at the annual meeting of the New England Surgical Society in 1939] basically said those with chronic pain were defective in some way," Meldrum noted. "When people had pain that couldn't easily be managed, they became increasingly suspect."
But things began to change.
"As society became more secularized and religion became less dominant, we became less willing to accept pain as punishment," Meldrum said. "The rise of Romanticism brought a greater empathy for the suffering of others, such as slaves, children, abused wives and eventually animals, and that spilled over into attitudes toward pain."
During World War II and after, John J. Bonica's work prompted the founding of the International Association for the Study of Pain. Bonica, an anesthesiologist, organized the first World Pain Congress 40 years ago. "That's why the pain field is so interesting," Meldrum told ADVANCE. "Most pain research has been done in the last 40 years. Most pain scales were developed after World War II."
Probably the first significant development in pain control was aspirin in 1899. "For the first time, people could take a pill and feel better. And unlike opium or alcohol, aspirin didn't make them fuzzy-headed," Meldrum said.
How Pain Works
Understanding the mechanism of pain is critical to creating medications and evidence-based pain protocols. The prevailing wisdom says pain sensation occurs when the nervous system conveys messages to the brain to, for example, pull your hand away when you touch your finger to a hot stove.
"If pain persists and the signals keep flooding the brain, they become integrated with all the other information transmitted via the nervous system, and can determine whether you have more pain," Meldrum said. "The more you're able to distract yourself from pain, the less severe it will seem and the more easily you'll be able to get over the pain. If all the neural systems interact and the brain keeps directing attention to the pain, it can create neurotoxicity; your nerves will become hypersensitive in the affected part of the body."
A big breakthrough in pain knowledge came in 1965 when Ronald Melzack, and Patrick Wall proposed the gate control theory. "They described a gate in the spinal cord that could open or close to allow pain signals to go to the brain," Meldrum explained. "Other sensory signals, or cognitive or affective inputs from the brain, open or close the gate. The idea is there is a pathway and if you interrupt the pathway, you can prevent the signals from reaching the brain; then the brain won't react. This could be used to bring chronic pain under control."
Scales, Research, Treatment
While pain research still is considered in its infancy, contemporary research is extensive and scientific, Meldrum said. "In the lab they are looking at MRIs and PET scans to determine what is happening in the brain of a person, at a certain level of pain. They are looking for a physiological sign of the level of pain, much as [blood pressure] is a measure of heart and circulatory health."
In addition, researchers are seeking a pain gene, "probably multiple genes," Meldrum continued. "If you can find some genetic predisposition to developing chronic pain and find a way to switch that gene off, just think how great that would be. This could be the Holy Grail of pain and probably will be discovered some day."
Whatever research is under way, pain treatment using evidence-based protocols based on present knowledge has advanced considerably. "We are more vigilant," Willens said. "We teach patients to communicate their pain better so we can help them. And no one should be in pain."
Right now, resources to control pain include tools like pain medications, patient-controlled analgesia, neurostimulation, anesthetic nerve blocks, TENS (transcutaneous electrical nerve stimulation), physical therapy, relaxation methods, meditation, yoga and legislation.
Yes, legislation. "It's a law in New Jersey that all healthcare providers at all levels must ask a patient about pain upon assessment," Kaes said.
Gail O. Guterl is a frequent contributor to ADVANCE.